Extrapyramidal Symptoms and Insulin Resistance in a Patient on Multiple Antipsychotics Therapy

Background/Objective: Multiple Antipsychotics Therapy promote obesity and insulin resistance. This study aimed to describe a T2DM patient with extrapyramidal symptoms and hyperglycemia who was also on several antipsychotic therapies and to determine whether omission of all antipsychotics along with modification of antidiabetic therapy led to better glycemic control. Case Report: An uncontrolled T2DM female subject presented with tremor in both hands as well as in the right corner of her lips. She also having comorbid hypertension and hypothyroidism. On examination, she showed no signs of pallor, icterus, clubbing, cyanosis or edema. Central nervous system examination revealed a GCS of 15 and neurological examinations including motor and sensory responses were unremarkable in Nerve Conduction Study and MRI. her blood glucose levels showed poorly controlled diabetes (HbA1C – 9.5%, FBS – 278mg/dl, PPBS – 234mg/dl) in spite of taking OHAs. Her initial treatment plan included omission of all antipsychotics and reduction in dose of glimepiride to 4mg. This led to a drastic fall in the blood glucose levels. Her CBG levels were between 100mg/dl- 150 mg/dl. Soon after this, the dose of metformin was reduced to 1000mg, vildagliptin was omitted and a SGLT-2 inhibitor was added. This caused gradual improvement in her symptoms and subsequently the blood sugar levels and blood pressure were also within acceptable limits. Discussion: Diabetes and hyperglycaemic emergencies are linked to APDs. There may be several processes that mediate this. In insulin-sensitive cells such muscle cells, hepatocytes, and adipocytes, APDs can block the insulin signalling pathway, resulting in insulin resistance. When choosing a course of treatment, one must consider this elevated risk. Conclusion: Patients receiving multiple antipsychotics therapy are more likely to experience negative metabolic alterations. This case findings also highlight the importance of glycemic control in patients with acute or subacute onset movement disorders, irrespective of their past glycemic status. Keywords: Multiple Antipsychotics Therapy, insulin resistance, T2DM patient, extrapyramidal symptoms, hyperglycemia.